www.nesoindonesia.or.

id
info@nesoindonesia.or.id
Menara Jamsostek 20th Floor
Jalan Gatot Subroto 38
Jakarta 12710 Indonesia
T. (+62) 21 52902172

Orange Tulip Scholarship (OTS) Indonesia

Academic year 2017-2018
Application Form

1. PERSONAL INFORMATION

Full name CYNTHIA NURINGTYAS ADIANTI Male Female

Address Jl. Perintis Kemerdekaan no 48 Laweyan - Solo

City & postcode Surakarta Click here to enter text.

E-mail cynthiaadianti@gmail.com

Mobile phone & telephone 081904210441 (0271)743060

Birthday (dd/mm/yyyy) 16/12/1995

Birthplace Surakarta

Nationality Indonesian

2. STUDY PROGRAMME IN THE NETHERLANDS

I am currently applying to one of the eligible programmes

Study programme: Click here to enter text.
Institution: Click here to enter text.

I have been accepted by the eligible Dutch institution in one of the eligible study
Current application status
programmes
Study programme: Double Degree Programme for undergraduate
Institution: Erasmus School of Economics, Erasmus University Rotterdam

(See list of eligible programmes and participating institutions at www.nesoindonesia.or.id/ots)

No
Yes (please specify below)

Institution Study programme

Click here to enter text. Click here to enter text.

Are you also applying to
other institutions under the Click here to enter text. Click here to enter text.
Orange Tulip Scholarship?
Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

You can apply to more than one OTS schemes. For each scheme, a separate OTS
application form needs to be submitted.

Orange Tulip Scholarship Indonesia 2016-2017 Application Form

30/10/2015
www.nesoindonesia.or.id
info@nesoindonesia.or.id
Menara Jamsostek 20th Floor
Jalan Gatot Subroto 38
Jakarta 12710 Indonesia
T. (+62) 21 52902172

3. ADDITIONAL OTS INDONESIA SCHEMES

If you would like to be considered for additional schemes, please write the additional scheme(s) that you are interested in.
IMPORTANT: Please regularly check the offered additional schemes and the requirements at
www.nesoindonesia.or.id/ots

Additional scheme 1: Click here to enter text.

Additional scheme 2: Click here to enter text.
Additional scheme 3: Click here to enter text.

4. ACADEMIC BACKGROUND
Name of last/current
Universitas Gadjah Mada
education institution
City & country Yogyakarta Indonesia

Study programme S1 (Bachelor)

Level of degree (to be)
High school Bachelor Master PhD
obtained
(Expected) month & year
February/2018
of graduation (mm/yyyy)

GPA 3.53 out of 4

English exam score &
month + year taken
GRE test result (if applicable)
GMAT test result (if
applicable)
iBT (month+year):
IELTS :
Click here to enter I have not taken an exam yet
JUNE/2016
text.
Month & year taken: Click here to enter
Click here to enter text.
text.
Month & year taken: Click here to enter
Click here to enter text.
text.

5. WORKING EXPERIENCE
Current or last working experience (If applicable). Please include your curriculum vitae on a separate file

Company/ organization: Click here to enter text.

Job position: Click here to enter text.

Short job description (max. 2 lines): Click here to enter text.

Other working experience(s) (max. 2 lines): Intern In Bank Central Of Indonesia for 1 month (December 21th 2016
January 21th 2017

6. FINANCING YOUR STUDIES

How do you plan to finance your studies at the Dutch higher education institutions (multiple answers possible)?
My own savings Bank credit/loan
Parents or family Scholarship(s)
Employer Other: Click here to enter text.

Orange Tulip Scholarship Indonesia 2016-2017 Application Form

30/10/2015
www.nesoindonesia.or.id
info@nesoindonesia.or.id
Menara Jamsostek 20th Floor
Jalan Gatot Subroto 38
Jakarta 12710 Indonesia
T. (+62) 21 52902172

Please specify other scholarships that you are applying to:

Click here to enter text.

7. CHECK REQUIRED DOCUMENTS

Please check the required documents of each scheme at www.nesoindonesia.or.id/ots

Please send the required documents to Nuffic Neso Indonesia (ONLY softcopy to ots@nesoindonesia.or.id) before 1 April
2017 (unless the institution for which you are applying mentions a different deadline on the Orange Tulip Scholarship
website). Incomplete forms and packages will not be taken into account.

PLEASE NOTE THAT EACH ORANGE TULIP SCHOLARSHIP SPONSOR MAY REQUIRE ADDITIONAL DOCUMENTATION. PLEASE
READ CAREFULLY THE INFORMATION ON THE NUFFIC NESO INDONESIA ORANGE TULIP SCHOLARSHIP WEBPAGE

All data will be treated strictly confidential by Nuffic Neso Indonesia and the selected Dutch higher education institutions,
solely for the purpose of the Orange Tulip Scholarship Indonesia programme application.

I certify that the information I have provided in this form is true, complete and correct.

Place : Surakarta

Date : Click here to enter text.

Name : Cynthia Nuringtyas Adianti

Signature : Click here to enter text.

Orange Tulip Scholarship Indonesia 2016-2017 Application Form

30/10/2015